Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Monday, November 12, 2007

While in a hurry to write orders on a patient with community acquired pneumonia, I ordered "Levaquin 750mg IV q D". The "D" of course meaning "Day" as it has for for the 17 years I have been writing it, and the 40 or 50 years other docs have been using the same abbreviation.

About an hour later while trying to repair a complex through and through laceration to the ear (with cartilage involvement) on a bipolar patient with severe anxiety, I got an urgent phone call. So I removed my gloves, broke my sterile field, and picked up the phone.

"You used the q D abbreviation on Mr. XXXXXX's admit orders" I was told in broken English.

"So what? And who is this?" I replied.

It was the pharmacist and he refused to send the med because the order wasn't written as q Day. My perfectly legible "D" is of course considered unapproved by JCAHAO and so in the "best interest of patient care", they refused to send up his antibiotic, and placed an urgent call to me during a complex lac repair!

Turns out that I couldn't just give a verbal order to change my D to Day, I had to personally change the order....so the floor refused to accept the patient because the orders weren't "complete" until I finished the lac repair and could go change them.

One more example of how government encroachment into medicine HARMS and DELAYS patient care in the interest of "patient safety". We put two patients at risk (granted the risk is low, but it was unnecessary) in order to make them "more safe". This is just absurd.

Just to follow up and make sure you know how dumb you were, you will probably be getting a formal letter from some committee because you didn't get blood cultures before administering the antibiotic, even tho they are positive in what 3% CAP cases! Oh and did you get the antibiotic in the pt inside the 4 hour window, even tho the pt had probably been sick for 4 or 5 days??

I feel much better after the formal flogging here on the blog. Thank you all for sharing in my shame. I awoke this am with the burden of disgrace that I have brought upon my family.

And to the Fart...I DID get those blood cultures, because that's "quality care" as defined by our hospital. (Yeah he had been sick for a week and was already on Keflex by some outside goombah who believes Keflex cures all ills...including MRSA).

As for the 4 hour window, I hope I made it since we have an "incentive". If we get antibiotics into 90% of the pneumonia patients within 4 hours of their presentation to the ED, we get $3,000 for our group of 15 docs to split each month!

Needless to say, lots of folks with CHF, asthma, or perihilar "schmutz" get their antibiotics! More "quality care" for you.

there's another problem with what you have written here erdoc85 and i do think it has the potential to cause harm.

as you know the proper way to finish a geometric proof is to write Q.E.D. (quod eratus demonstratum, or 'thus it is shown') below the proof.

i would not be at all surprised if the pharmacist, obviously highly trained in many of the hard sciences, thought that you were trying to prove a geometry problem and that you had not, in fact, satisfied the proof.

keep that in mind when you 'poo poo' these rules and regulations. someday you might recoil in embarrassment after someone mistakes you for saying that a all the angles of a triangle do not equal 180 or something.

Heh, when I worked on the floor, we had to call and clarify these orders, too, which was embarrassing to us as well because it inherently makes us sound like royal idiots. We were allowed to take verbal orders over the phone for "daily" instead of "Qday", however.

That being said, the last known doctor to have written "QD" hasn't been seen since. There was a house-wide meeting where we were told to tell "any interlopers" that "he up and moved to Tanzania", but I saw the poor chap the day before and he just said he was "going out to an Italian restaurant to talk with JCAHO". It's fishy as Hell, lemme tell ya.

It's pedantic asininity like this that makes me proud to be...a civilian!Y'all should NOT have to tolerate this crap. I'm prayin' real hard Socialized medicine does NOT become a reality;because if the .gov can screw things up this badly just by supervising paperwork and accreditation...I shudder to think what running the entire system will mean.

the problem with all governmental oversight, or bureaucratic oversight, or centralized oversight is that the process becomes more important than the problems they were designed to solve. then you have a bunch of people who get paid for the oversight and they come to believe that what they do is really important. sometimes it is, but really i'm hard pressed to think of when.

these folks probably have little real sense of accomplishment in what they do but there is strength in numbers. they are then emboldened and empowered. and good gracious, what is the last bureaucracy, paid committee position, or administrative oversight position that got cancelled because they got their job done?

About the "qD" issue: It is axiomatic that non-physician administrators WILL put in place and enforce moronic rules like this. The ONLY way (unfortunately) to control this is for MDs to fight this crap, item by item, in any forum that is available. For example, policies like this (e.g. hospital set 'critical values') are actually set and approved at my hospital by physician led committees. Because generally MDs despise sitting in committees, we just eat whatever shit is recommended by some outside agency / entity (e.g. ASCP, CAP etc...). There ARE things we can control, but only if we stand at the vanguard and insist that the bullshit does not fly. I HATE having to sit through these committees and be the asshole in the room, but the alternative (eating someone else's shit) is unacceptable.

I think most MDs got into medicine to treat patients and NOT to be administrators. But this is being forced on us. Either stand up and don't let them fuck you, or bend over, smile, and take it in the ass. These are the two choices...

ERDOC85,If I had been one of your nurses, I would have taken care of the problem and you wouldn't even have known about it...well, you would have overheard us (nurses) making fun of the pharmacist/system.Isn't "D/C" one of the abbrev they tried to, uh, D/C?

Yes, D/C is one of those abbreviations on the list...when I write D/C home, it just might confuse the staff as to whether I wanated to discharge the patient, discontinue the patient, or send him for a D AND C. So, thankfully JCAHCO has stepped in to make patients more safe.

Isn't it ironic that the institution with the most acronynyms and abbreviations in the WORLD...the US GOV is trying to stop confusion in our arena (where none existed before).

I'll be happy to write out "discharge" and "daily" and all of the other shit, but in return, they can no longer call themselves JCAHAO. They have to write out Joint Commission for the Accreditation of Health Care Organizations. I find the JCAHAO title confusing and therefore I think it's unsafe.